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OBJECTIVES: The effect of the Tobacco Hazards Prevention Act (THPA) on the reduction of tobacco use in the general population in Taiwan is understood. However, there has been little research on how these policies affect people with severe and persistent mental illness (SPMI). Hence, the influence of the THPA on daily cigarette use by patients with SPMI was investigated in a 3-year follow-up. The risk and protective factors in smoking behavior and cessation were investigated. STUDY DESIGN: This is an observational study. METHODS: A total of 144 participants (78 of whom had smoked >100 cigarettes throughout their lifetime) were randomly selected from a healthcare network. Then, 100 of 144 patients with SPMI, included 50 smokers and 50 non-smokers, have agreed with 1st year follow-up. Eighty-two patients with SPMI, consisted of 44 smokers and 38 non-smokers, have agreed with 2nd year follow-up. RESULTS: Although women were less likely to smoke than men, those who did smoke reduced the number of cigarettes less than men over the 3-year period. Less-educated patients were more likely to smoke than those who were more educated but reduced the number of daily cigarettes more after implementation of the THPA. Maternal overprotection was a risk factor and paternal care a protective factor for smoking. Addiction, a perception of pleasure, interpersonal relationships, and self-destructive behavior increased cigarette smoking. Patients perceived that smoking alleviated their depressive symptoms. CONCLUSIONS: The THPA was ineffective for patients with SPMI. Some factors had different effects on the development of smoking behavior and the cessation process. Understanding the etiology of smoking can help policymakers establish more effective programs for smoking prevention and cessation.

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OBJECTIVE: The effectiveness of suicide prevention programmes is an important issue worldwide today. The impact of urbanization and gender is controversial in suicide rates. Hence, this study adjusted on potential risk factors and secular changes for suicide rates in gender and rural/urban areas. STUDY DESIGN: Observational study. METHODS: A Suicide Prevention Center was established by the Executive Yuan in Taiwan in 2005 and tried to carry out suicidal intervention in the community in every city and town. There were two phases, including the first phase of the programme from 2005 to 2008, and the second phase of the programme from 2009 to 2013. The crude suicide rates data from the period of 1991-2013, which recruited nine urban and 14 rural areas in Taiwan, were extracted from the Taiwanese national mortality data file. The suicide rates in two areas of Taiwan (Taipei city and Yilan County) were further used to compare the differences between urban and rural areas. RESULTS: The results show that unemployment increased the suicide rate in men aged 45-64 years and in women older than 65 years of age in Taiwan. High divorce and unemployment rates resulted in increased suicide rates in men in the city, whereas emotional distress was the main cause of suicides in men in rural areas. The main method of suicide was jumping from a high building for both sexes in the city, whereas drowning was the most common method of suicide for men in rural areas. CONCLUSION: Following the intervention programme, suicide behaviour began to decrease in all urban and rural areas of Taiwan. This study showed the cumulative effect of the intervention programme in decreasing the suicide rate in Taiwan. Moreover, the gender-specific suicidal rate and disparity in suicidal methods in urban and rural areas should be considered in further preventive strategies in Taiwan.

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BACKGROUND: This study examined the prevalence of major depressive disorder (MDD), and the correlations and co-morbid conditions associated with MDD, in the adult Taiwanese population, which a previous estimate in the 1980s had found to be at the lower end of the spectrum worldwide. Possible explanations for the reported low prevalence of MDD were evaluated. METHOD: As part of a survey of common psychiatric disorders in a nationally representative sample of individuals aged ≥ 18 years who were non-institutionalized civilians in Taiwan, a face-to-face interview using the paper version of the World Mental Health Survey of the World Health Organization (WHO) Composite International Diagnostic Interview (WMH-CIDI) was conducted between 2003 and 2005. Functional impairment and help-seeking behaviors were compared between Taiwanese subjects with MDD and their counterparts in the USA. RESULTS: Among the 10 135 respondents, the lifetime prevalence of MDD was 1.20% [standard error (S.E.)=0.2%]. Individuals who were divorced or widowed, aged ≤ 40 years, and female were at increased risk, whereas rural residents were at lower risk for MDD. The proportion of MDD cases co-morbid with other psychiatric disorders in this study was much lower than in the US study. Only one-third of Taiwanese individuals with MDD sought help despite having twice the number of lost workdays compared with the US sample. CONCLUSIONS: Despite the low prevalence of MDD in Taiwanese adults, the pattern of low help-seeking behavior and profound functional impairment indicates much room for improvement in the early detection of and intervention in major depression in this population.

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BACKGROUND: As part of an ongoing clinical service programme for pre-school children with developmental delay in an Asian developing country, we analysed the effect of three assessment tests, that is, Bayley Scale of Infant Development-II, Leiter International Performance Scale - Revised and Wechsler Preschool and Primary Scale of Intelligence - Revised - Chinese, on the stability of intelligence quotient (IQ) of children from pre-school through early childhood. METHODS: The participants were 313 Taiwanese pre-school children with uneven or delayed cognitive profile and they were followed through early childhood. IQ stability was explored by different tests and among children of different clinical diagnosis: 168 children with non-autistic intellectual disability, 73 children with autism spectrum disorder, 58 children with mixed receptive-expressive language disorder and 14 children of other heterogeneous diagnoses. Stability of scores was evaluated using the r-squared for Pearson's coefficients to see the correlation between initial IQ (IQ1) and follow-up IQ (IQ2). Multiple linear regressions were also applied to see whether IQ1 had predictive ability for IQ2 and test-test difference in the total 313 children and each diagnostic subgroup. RESULTS: Results revealed that mean IQ1 was 65.8 ± 15.4 while mean IQ2 was 73.2 ± 17.9 for the total 313 children. The IQs were stable across an average follow-up duration of 38.6 ± 22.1 month from pre-school into early childhood. Patterns of positive correlations between IQ1 and IQ2 were noted by all the tests (r-squared = 0.43-0.5, all P < 0.001) and in the majority of diagnostic subgroups. Multiple regressions analysis also revealed that IQ1 could predict IQ2 significantly in all the tests (all P < 0.001). DISCUSSION: After careful choice of appropriate initial test, stability of IQ in children with developmental delay was noted from pre-school through early childhood. In addition, the translated version of cognitive assessment was valid for the required context of an Asian developing country. With the current emphasis on early identification and intervention for pre-school children with developmental delay, this information bears merit in clinical practice.

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BACKGROUND: This study investigated a possible pathway of the childrearing context and maternal mental health at 6 months, and how these factors influence children's development at 6, 18 and 36 months. METHODS: Using random sampling, 2048 children and mothers were selected. The mother's health status was evaluated using the Taiwanese version of the 36-Item Short Form Health Survey (SF-36), and infant development was assessed using the high reliable Taiwan birth cohort study instrument. All data were collected using parental self-report, and were analysed using multiple linear regression analysis and further pathway using structural equation modelling. RESULTS: This study showed that 12 factors effected children's development at 6 months, and some dissipated with growth. Of these, maternal education had an enduring effect on different domains of child development, and this effect intensified as the child grew older. Children who grew up in a family with more siblings would show a delay in language development at 6 months; they have a delay in motor and social development at 18 and 36 months. Additionally, maternal mental health effected the children's fine motor development at 6 months. However, this effect disappeared at 18 months, and influenced children's social development at 36 months. CONCLUSIONS: This study demonstrated that the development of children at as young as 6 months is affected by various factors. These factors may dissipate, continue to influence child development up to 3 years of age, turn from being disadvantageous to beneficial, or affect different domains of child development. Also, parental self-report instrument might be has its limitation and could be contributed by several confounding factors. Thus, continuous longitudinal follow-up on changes in maternal conditions, family factors, and environmental factors is vital to understand how these early infantile factors affect each other and influence the developmental trajectories of children into early childhood.

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We report the first genome-wide association study in 1000 bipolar I patients and 1000 controls, with a replication of the top hits in another 409 cases and 1000 controls in the Han Chinese population. Four regions with most strongly associated single-nucleotide polymorphisms (SNPs) were detected, of which three were not found in previous GWA studies in the Caucasian populations. Among them, SNPs close to specificity protein 8 (SP8) and ST8 α-N-acetyl- neuraminide α-2,8-sialyltransferase (ST8SIA2) are associated with Bipolar I, with P-values of 4.87 × 10(-7) (rs2709736) and 6.05 × 10(-6) (rs8040009), respectively. We have also identified SNPs in potassium channel tetramerization domain containing 12 gene (KCTD12) (rs2073831, P=9.74 × 10(-6)) and in CACNB2 (Calcium channel, voltage-dependent, ß-2 subunit) gene (rs11013860, P=5.15 × 10(-5)), One SNP nearby the rs1938526 SNP of ANK3 gene and another SNP nearby the SNP rs11720452 in chromosome 3 reported in previous GWA studies also showed suggestive association in this study (P=6.55 × 10(-5) and P=1.48 × 10(-5), respectively). This may suggest that there are common and population-specific susceptibility genes for bipolar I disorder.

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Personality has been proposed as having a possible effect on the reaction that patients have toward auditory hallucination. However, this factor has not been studied previously. Thus, this study investigated the relationship among demographics, personality, cognition and emotional response in schizophrenics with persistent auditory hallucination. One-hundred and fourteen subjects with persistent auditory hallucination completed the Eysenck Personality Questionnaire, the revised Beliefs about Voices Questionnaire and the Chinese-version Hospital Anxiety and Depression Scale. Structural equation model showed that personality had an effect on beliefs about the hallucination (malevolent or benevolent), which then affected the reaction of patients toward these voices (engages or resists). Their reaction will further affect the anxious or depressed state of the patients. When these hallucinations were categorized into the three levels of omnipotence, beliefs and reactions, the model was more significant than that of one-level model. Persistent auditory hallucination only accounted for a portion of the emotional distress when malevolent or benevolent voices were perceived, and personality characteristics accounted for the remaining emotional distress in schizophrenics. This model helped us understand the relationship between personality, cognition and affective symptoms, such that, when therapists decide what "trait" to change, they can determine at which point to intervene.

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BACKGROUND: While studying the development of twins, gestational age and birthweight were suggested as two of the major mediators to be considered. In addition, maternal age, maternal education, parental income and assisted reproductive technologies (ART) also should be considered as moderators. Thus the purpose of this study was to investigate the mediators and moderators of twin and singleton development. METHODS: Being a national birth cohort study, 21 648 infants were randomly selected and developmental measures were assessed at 6 and 18 months post partum. Children's development at 6 and 18 months were measured using the high reliable Taiwan Birth Cohort Study instrument, which measures children's development in four domains of gross motor, fine motor, language and social development. Additionally, maternal sociodemographics including maternal age, maternal education and parental income; children's characteristics including gender, birthweight, gestational age, single or multiple births, ART or natural conception information were also collected. These data were analysed using a three-step multiple linear regression analysis and further validated using structural equation modelling. RESULTS: Parental sociodemographics, children characteristics and being twin all had effect on children's development. Additionally, ART and twin were mediators between maternal age and children's development. Mothers aged over 40 were more likely to choose ART, thus increases their likelihood of having twins. Additionally, mothers aged over 40 were more likely to give birth to premature or low-birthweight babies, regardless if they were twin or not. Twins had a higher prevalence of prematurity or low birthweight, which also affected their development in all four domains at 6 and 18 months. Thus prematurity and low birthweight were mediating factors between twin and children's development; with these two mediating factors controlled, there were no difference between twin and singleton development. CONCLUSIONS: The conceptual construct of structural equation modelling showed these factors interacted and influenced children's development through multiple pathways. Medical intervention may facilitate children's development through prenatal growth and premature care.

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OBJECTIVE: Major depression is an important comorbidity in Alzheimer's disease, which is definitely associated with the apolipoprotein E (apo E) polymorphism. The aim of this study was to explore the role of the different apo E polymorphisms in major depressive disorder (MDD) in a Taiwanese population. METHOD: We examined apo E genotypes in 273 Taiwanese patients with MDD and 429 healthy community controls, and compared their polymorphism distribution. RESULTS: The allelic frequency of apo epsilon2 was significantly lower in patients with MDD than in the controls, whereas no significant difference in apo epsilon4 allelic frequency between these two groups was found. CONCLUSION: The apo epsilon4 allele was not associated with MDD in this study. However, the finding of a lower frequency of the apo epsilon2 allele in MDD could lead to the conclusion that the apo epsilon2 allele likely provides a protective effect against MDD in the Taiwanese population.

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BACKGROUND: The purpose of this research was to investigate the relationship between marriage-related risk factors during maternal pregnancy and subsequent development of attention-deficit hyperactivity disorder (ADHD). METHODS: The research design was a retrospective case-control study. The case group included 60 patients that fulfilled the ADHD criteria of Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The controls were normal children randomly selected and matched for their sex and age. Their biological mothers completed a questionnaire about marital adaptation, marital satisfaction and the incidence of stressful life events during pregnancy. RESULTS: The results showed that the incidence of positive life events, marital adaptation and marital satisfaction during maternal pregnancy was significantly lower in the case group, and conditional logistic regression analysis showed that marital adaptation during pregnancy and pregnancy before marriage were important risk factors for ADHD. CONCLUSION: Negative emotion during maternal pregnancy may be an important risk factor for ADHD.

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BACKGROUND: The purpose of this study was to explore the effect of support groups on the mental health and quality of life for mothers with autistic children. METHOD: A quasi-experimental pre-post control group design was used in this study. The mothers had children without chronic diseases diagnosed as autistic based on Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) and were their primary caregivers. The mothers were assigned to control or intervention groups based on their willingness. The 10 weeks of the support group programme served as an intervention. There were three waves of data collection: pre-test, post-test, and after 1 month follow-up. A total of 27 mothers with autistic children were assigned into experimental and control groups. In total, there were eight mothers in the experimental group and 19 mothers served as the control group. RESULTS: The results of this study showed that mental health had not significantly improved in the intervention group compared to those in the control group at the end of the first month during follow-up. However, the subjective well-being and employment status had an effect on their mental health. Only the subjective well-being had an effect on their quality of life. CONCLUSION: According to the results of this study, recommendations included (1) regularly promulgating a caregiver support group, (2) the advancement of training skills within the group, and (3) upgrading and promoting nurses' ability to lead support groups in the future.

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OBJECTIVE: This study aimed to determine the impact of the present of apolipoprotein epsilon (Apoepsilon) 2 on the relationship between Apoepsilon4 and Alzheimer's disease (AD). METHOD: We examined ApoE genotypes in 428 Taiwanese patients with AD and 807 controls; all participants were older than 65 years. RESULTS: The allele frequency of Apoepsilon4 was greater in AD patients than controls, but significantly lower than in Caucasians. The presence of an epsilon2 allele alone was not associated with lower risk for AD, but the presence of an epsilon2 allele was associated with an epsilon4 allele frequency similar to that of controls. CONCLUSION: The low allele frequency of epsilon4 in persons with an epsilon2 allele suggests that this may be part of the protective effect of epsilon2 against AD.

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BACKGROUND: The aims of the present study were to describe the change in mental health over time in a group of family caregivers with a child with intellectual disability (ID) and to explore the effect of a home care service on the psychological well-being of the caregiver. METHODS: The authors identified children with ID who received home care services in the southern part of Taiwan. A total of 46 primary family caregivers (age range = 21-65 years) were recruited for the present study. The study design was a quasi-experimental follow-up analysis. The children with ID and their families regularly received home-based care. The 12-item version of the Chinese Health Questionnaire (CHQ) was used to evaluate the subjects' mental health at three time points: (1) baseline, (2) 3 months and (3) 9 months. The validity and reliability of the CHQ have been tested in Taiwan. The Generalized Estimating Equation was used to conduct longitudinal data analyses. RESULTS: The authors found that the family caregivers showed a significant improvement in their mental health by month 9. CONCLUSIONS: The preliminary findings of this study accredit the effect of home care services and suggest that home care services are necessary for family caregivers.

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The purpose of this study was to examine differences between Taiwanese children with autism and their typically developing peers on the Wisconsin Card Sorting Test (WCST). Twenty-six children with autism of normal IQ were included, and matched for chronological age with 52 controls. The WCST scores of the typically developing children were significantly higher for categories completed and percent conceptual level than in the autism group. Scores on perseverative responses, perseverative errors, the number of trials to complete the first category and non-perseverative errors were significantly higher in the autism group. The implications of these findings are discussed.

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We aimed to determine the association and related factors of the apolipoprotein E (ApoE) genotype and Alzheimer's disease (AD) in Taiwan. We examined ApoE genotypes in 50 Chinese patients with AD and 50 age- and sex-matched controls. The patients met the criteria of probable AD of the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and AD of the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV). There were 28 females and 22 males in the case and control groups. The mean age of onset of AD was 72. 62 years. The average interval between onset and research was 3.85 years. The frequency of ApoE epsilon 4 in the AD group was significantly higher than that in the controls (0.13 versus 0.02, p < 0.05). The odds ratio for AD in individuals with at least one ApoE epsilon 4 allele was 6.0 (95% CI 1.34 to 55.3, p < 0.001). The linear trend for AD in proportion to alleles of ApoE epsilon 4 was significant (chi 2 = 8.3, p = 0.004). The risk of ApoE epsilon 4 allele for the late-onset AD patients, males, or those who received less education was higher than that for the early-onset AD patients, females, or those who had received more education. The sensitivity of the epsilon 4 allele was 24%, the specificity 96%, the positive predictive value 86%, and the negative predictive value 56%. Our results supported that the ApoE epsilon 4 allele is related to AD in Taiwan. In addition, sex and education may play important roles in the presence of ApoE epsilon 4 allele. The epsilon 4 allele seemed helpful as an adjunct for diagnostic testing of AD.

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Community-based services are being developed as mental health services. The purpose of this study was to examine the effect between home care and half-way house services on patients with schizophrenia. The design was quasi-experimental and used repeated measurements. There were 60 subjects, 37 receiving home care and 23 receiving half-way house care which were affiliated with one general hospital in the south of Taiwan. Of the 60 chronic schizophrenic patients, there were 34 males and 26 females with an average age of 34 years. The Quality of Life Scale was applied to measure each patient four times, at an interval of two months. These follow-up data were analyzed by Generalized Estimating Equation-I (GEE-I) because repeated observations on an individual may be correlated. The result showed that the total QOL in patients receiving home care programs was significantly higher than those receiving half-way house service. The total scores of QOL in patients under half-way house and home care services did not show secular change. The patients under home care program showed a somewhat improvement for a short period of time. However, as time went on, the patients showed no obvious improvement in their life quality. The dimensions of independence and social activity in QOL also showed significantly different between these two groups. The results may provide guides on designing programs and activities for the chronic mental patients. However, the best decision to apply which program for patients need continouous and comprehensive assessment.

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The aim of this study was to investigate the impact of autistic children on the mental health of their mothers. Autism is a complicated neuropsychiatric disorder. Evidence shows that mothers with autistic children experience greater stress than those having children with other chronic diseases. In this study we have 1) assessed the mental health of mothers with autistic children; 2) determined their prevalence of minor psychiatric morbidity (MPM); 3) classified their MPM; and 4) determined factors related to their mental health. A case-controlled design was used to compare the mental status among mothers having children with either autistic (n = 30), or Down syndrome (n = 11) and with normal children (n = 56). The mean score of the Chinese Health Questionnaire (CHQ) showed no differences between those mothers of case and control groups. Using a 9-point criterion to screen for MPM in the CHQ, more mothers (37%) in the case group had scores > or = 9 compared with the control group (18%). Mothers of the case group had significantly higher for MPM using logistic regression analysis. The educational level was inversely related to the CHQ scores. Mothers with a CHQ score > or = 9, were later diagnosed with either depression (36%) and anxiety (46%); or anxiety and depression (9%). A primary care model for mothers with autistic children should therefore be developed to prevent them from developing mental disorders.

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The main aims of this study were to develop norms for the Wisconsin Card Sorting Test in 6- to 11-year-old children in Taiwan; to explore the effect of sex, age, birth order, number of siblings, and parental education on WCST performance in 6- to 11-year-old children; and to make a comparison of WCST performance between children in Taiwan and the USA. The results of this comparison of developmental norms of school children in Taiwan and the United States may facilitate the WCST as a clinical or research instrument in combination with other test procedures to assess aspects of cognitive and neuropsychological functioning of school children.

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